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State of Oregon

Evidence-based
Clinical Guidelines
Project
Evaluation and Management
of Low Back Pain
A Clinical Practice Guideline Based on the Joint Practice Guideline of
the American College of Physicians and the American Pain Society
(Diagnosis and Treatment of Low Back Pain)

October 2011

State of Oregon Evidence-based Clinical Guidelines Project

Guideline Development Group


Jeanene Smith, MD, MPH; David Pass, MD; Darren Coffman, MS
Office for Oregon Health Policy and Research
Cat Livingston, MD, MPH
Office for Oregon Health Policy and Research [Consultant]
Oregon Health & Science University
Mylia Christenson
Oregon Health Care Quality Corporation
Steven D. Marks, MD, MHA
PacificSource Health Plans
Oregon Health Leadership Council
Valerie King, MD, MPH; Alison Little, MD, MPH; Catherine Pettinari, PhD; Aasta Thielke, MPH;
Cathy Gordon, MPH
Center for Evidence-based Policy, Oregon Health & Science University
Suggested Citation
Livingston, C., King, V., Little, A., Pettinari, C., Thielke, A., & Gordon, C. (2011). State of Oregon
Evidence-based Clinical Guidelines Project. Evaluation and management of low back pain: A
clinical practice guideline based on the joint practice guideline of the American College of
Physicians and the American Pain Society (Diagnosis and treatment of low back pain). Salem:
Office for Oregon Health Policy and Research. Available at:
http://www.oregon.gov/OHA/OHPR/HERC/Evidence-Based-Guidelines.shtml

This document was prepared by the Center for Evidence-based Policy at Oregon Health &
Science University (the Center) on behalf of the Guideline Development Group and the Office
for Oregon Health Policy & Research. This document is intended to help providers, consumers
and purchasers of health care in Oregon make informed decisions about health care services.
The document is intended as a reference and is provided with the understanding that neither
the Center nor the Guideline Development Group are engaged in rendering any clinical, legal,
business or other professional advice.
These guidelines should not be construed as dictating an exclusive course of treatment or
procedure. Variations in practice may be warranted based on the needs of the individual
patient, resources, and limitations unique to the institution or type of practice.
The statements in this document do not represent official policy positions of the Center, the
Guideline Development Group, or the Office for Oregon Health Policy and Research.
Researchers and authors involved in preparing this document have no affiliations or financial
involvement that conflict with material presented in this document.

Evaluation & Management of Low Back Pain (October 2011)

State of Oregon Evidence-based Clinical Guidelines Project

Objective
This guideline was developed by a collaborative group of public and private partners to provide up-todate evidence-based guidance on the evaluation and management of low back pain. The purpose of this
guideline is to assist licensed clinicians, working within their scope of practice in the State of Oregon, in
the assessment and management of low back pain among non-pregnant adults. Implementation of
recommendations in this guideline will be determined by individual health plans and providers.
Background
In June 2009, the Oregon legislature passed health reform legislation, HB 2009, which created the
Oregon Health Policy Board and charged it with creating a comprehensive health reform plan for our
state. In December 2010, the Board released Oregons Action Plan for Health, which lays out strategies
that reflect the urgency of the health care crisis and a timeline for actions that will lead Oregon to a
more affordable, world-class health care system. They outlined eight foundational strategies, one of
which is to set standards for safe and effective care. To accomplish this, the plan directs the state to
Identify and develop 10 sets of Oregon-based best practice guidelines and standards that can be
uniformly applied across public and private health care to drive down costs and reduce unnecessary
care. This work will be conducted by the Health Services Commission and Health Resources Commission
in close collaboration with providers, the Center for Evidence-Based Practice, and other key
stakeholders. 1
During the same time period when this guideline was under development by the State of Oregon, the
Oregon Healthcare Leadership Council and the Oregon Health Care Quality Corporation both
independently began pursuing the development of practice guidelines that could be used across the
state, and the value of collaboration became apparent. The three entities agreed to develop the first
guideline together, and in the fall of 2010, selected Evaluation and Management of Low Back Pain as
their first guideline topic. Representatives from the three organizations formed the Guideline
Development Group (GDG), while clinical evidence specialists from the Center for Evidence-based Policy
provided expertise and research to support guideline development.
Methods
The GDG was guided in developing this guideline by the ADAPT2 framework which is a systematic
approach to the endorsement or modification of guideline(s) produced in one cultural context or
organization setting for application in another context. Guideline adaptation is used as an alternative to
wholly new guideline development, which is time consuming, expensive and an inefficient use of
resources, when quality guidelines are available.
The process for developing this guideline began by searching 17 different databases and other sources
for guidelines related to Acute Low Back Pain (see appendix A). Candidate guidelines were required to
be evidence-based (recommendations based on a systematic review of the literature), address the
comprehensive clinical management of adults with an acute episode of low back pain, be published in
English and be widely available. By comprehensive, the GDG meant that the guideline would include
recommendations on the initial assessment of a patient with a new episode of low back pain, the use of
both pharmacologic and nonpharmacologic therapies and the appropriate ongoing management of
1

Effective January 1, 2012, House Bill 2100 (2011) terminates the Health Services Commission and Health Resources
Commission and transfers their duties related to evidence-based guideline development to a new Health Evidence
Review Commission.
2
http://www.adapte.org/www/

Evaluation & Management of Low Back Pain (October 2011)

State of Oregon Evidence-based Clinical Guidelines Project

people who experience continuing low back pain. The GDG required that evidence-based
recommendations be made on the basis of both the quality and strength of the underlying data from the
guidelines systematic reviews.
Thirteen candidate guidelines were identified, of which 10 were sufficiently comprehensive to address
most management issues (Appendix B). Those 10 guidelines were then assessed for methodologic
quality using a modified AGREE (Appraisal of Guidelines Research and Evaluation) II3 instrument
(Appendix C) by two different guideline quality assessors from the Center for Evidence-based Policy. Five
of those guidelines were rated either Good quality, or Fair quality with Good rigor of development
according to the modified AGREE rating tool. These five guidelines were then examined further for
scope and clarity of presentation.
After considering guideline age, source, specific treatment elements addressed and presentation, the
GDG selected the two guidelines of highest quality that were most comprehensive. The two selected
were both good quality and completed in the last five years, whereas the other three were more than 5
years old and were rated fair quality. Of the two selected, the American College of Physicians/ American
Pain Society (ACP/APS) guideline was preferred as the base guideline, primarily because it had
recommendations concerning the early care of acute low back pain and contained algorithms that were
felt to be useful implementation tools.
The ACP/APS guideline in its entirety can be found at the following link:
http://www.annals.org/content/147/7/478.long. The ACP/APS guideline is accompanied by full
systematic reviews on nonpharmacologic therapies for low back pain
(http://www.annals.org/content/147/7/492.full.pdf+html) and the use of medications for low back pain
(http://www.annals.org/content/147/7/505.full.pdf+html). Comparison was then made to the other
high quality, comprehensive guideline, which was produced by the National Institute for Health and
Clinical Excellence (NICE). The full NICE guideline and reviews of the evidence are available at the
following link: http://www.nice.org.uk/CG88. There were two significant areas of difference. First,
the NICE guideline does not address treatment in the first six weeks. Second, the NICE guideline
excludes patients with leg pain or radiculopathy. However, there were no significant differences in other
assessment or treatment recommendations between the two guidelines.
The GDG found no guidelines that focused exclusively on acute low back pain during the first 12 weeks
of the episode of back pain. This is primarily because many of the studies in the field include people with
back pain of longer duration. The GDG felt that the ACP/APS guideline concentrated on acute low back
pain and was also able to contribute guidance toward those patients experiencing more persistent or
recurrent back pain. For this reason, the GDG decided to change the focus of the guideline to the
evaluation and management of low back pain, regardless of duration. Figure 1 & 2 of the guideline are
an algorithm that addresses the initial assessment and management of low back pain, as well as
provides management options including both pharmacologic and nonpharmacologic interventions.
The ACP/APS guideline used the ACPs guideline grading system that was adapted from the Grading of
Recommendations, Assessment, Development, and Evaluation (GRADE) working group. Guideline
recommendations were rated as either strong or weak. Strong recommendations were required to have
clear evidence of benefit or harm. Weak recommendations were based on finely balanced benefits, risks
and burdens. The overall strength of evidence for each intervention was rated based on factors such as
3

http://www.agreecollaboration.org/

Evaluation & Management of Low Back Pain (October 2011)

State of Oregon Evidence-based Clinical Guidelines Project

the quality, quantity, consistency, generalizability and directness of the evidence. The ACP/APS guideline
panel considered interventions to have proven benefit if there was at least fair quality evidence of
moderate or substantial benefit (or of small benefit with no significant harms, costs or burdens).
Updating
The ACP/APS guideline was published in 2007. The authors of the guideline were contacted in March
2011 and stated that there had been no new published evidence which would change the
recommendations of the guideline and that it was considered current. The GDG recommends that this
guideline be reevaluated if the ACP/APS issues an updated guideline and at least every two years for
currency if the original guideline is not updated.

Recommendations
Below are the recommendations of the ACP/APS clinical practice guideline. The GDG found that all of
these recommendations apply to the objectives and purposes stated above. The recommendations
relate to the algorithm which follows (Figure 1 and Figure 2 from the guideline publication) and the
algorithm makes reference to the specific numbered guideline recommendations below.
Recommendations 2, 3 and 4 are further supported by a systematic review and meta-analysis of imaging
strategies published in 20094, as well as Best Practice Advice from the American College of Physicians
published in 20115.

Table A: State of Oregon Evidence-based Clinical Guideline Recommendations for the


Management of Low Back Pain
Recommendations
Recommendation

Content

Strength of Recommendation &


Evidence Grade

1.

Clinicians should conduct a focused history and physical


examination, including a neurological exam, to help
place patients with low back pain into 1 of 3 broad
categories: nonspecific low back pain, back pain
potentially associated with radiculopathy or spinal
stenosis or back pain potentially associated with another
specific spinal cause. The history should include
assessment of psychosocial risk factors, which predict
risk for chronic disabling back pain. Appropriate referrals
for management of potentially serious conditions (see
6
Table B) could be considered at this time.

Recommendation: Strong

Focused History &


Physical

Grade: Moderate-quality
evidence

Chou, R, Fu, R, Carrino, J & Deyo, R. (2009). Imaging strategies for low-back pain: systematic review and meta-analysis.
The Lancet, 373(9662): 463-72.
5
Chou, R, Qaseem, A, Owens, D, Shekelle, P for the Clinical Guidelines Committee of the American College of Physicians.
(2011). Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians.
Annals of Internal Medicine, 154(3), 181-189.
6
Making referrals for management of psychosocial risk factors predictive of chronic disabling back pain are not
supported by evidence at this time.

Evaluation & Management of Low Back Pain (October 2011)

State of Oregon Evidence-based Clinical Guidelines Project

Recommendations
Recommendation

Content

Strength of Recommendation &


Evidence Grade

2.

Clinicians should not routinely obtain imaging or other


diagnostic tests in patients with nonspecific low back
pain.

Recommendation: Strong

Clinicians should perform diagnostic imaging and testing


for patients with low back pain when severe or progressive neurologic deficits are present or when serious
underlying conditions are suspected on the basis of
history and physical examination.

Recommendation: Strong

Routine Imaging for


non-specific pain

Grade: Moderate-quality
evidence

(X-ray, CT, MRI)


3.
Imaging for
underlying
conditions present
or suspected

Grade: Moderate-quality
evidence

(See Table B for a list of potentially serious conditions)

(X-ray, CT, MRI)


4.
Advanced Imaging
(CT, MRI)

5.
Patient Education

6.
Pharmacologic
therapy

Clinicians should evaluate patients with persistent low


back pain and signs or symptoms of radiculopathy or
spinal stenosis with magnetic resonance imaging
(preferred) or computed tomography only if they are
potential candidates for surgery or epidural steroid
injection (for suspected radiculopathy).

Recommendation: Strong

Clinicians should provide patients with evidence-based


information on low back pain with regard to their
expected course, advise patients to remain active, and
provide information about effective self-care options.

Recommendation: Strong

For patients with low back pain, clinicians should


consider the use of medications with proven benefits in
conjunction with back care information and self-care.
Clinicians should assess severity of baseline pain and
functional deficits, potential benefits, risks, and relative
lack of long-term efficacy and safety data before
initiating therapy.

Recommendation: Strong

Grade: Moderate-quality
evidence

Grade: Moderate-quality
evidence

Grade: Moderate-quality
evidence

Note: For most patients, first-line medication options are


acetaminophen or non-steroidal anti-inflammatory
drugs
7.
Non-pharmacologic
therapy

For patients who do not improve with self-care options,


clinicians should consider the addition of nonpharmacologic therapy with proven benefitsfor acute low
back pain, spinal manipulation; for chronic or subacute
low back pain, intensive interdisciplinary rehabilitation,
exercise therapy, acupuncture, massage therapy, spinal
manipulation, yoga, cognitive-behavioral therapy, or
progressive relaxation.

Evaluation & Management of Low Back Pain (October 2011)

Recommendation: Weak
Grade: Moderate-quality
evidence

State of Oregon Evidence-based Clinical Guidelines Project

Figure 1. Initial evaluation & management of low back pain (LBP).


1

Adults with LBP

Perform a focused history and physical examination,


evaluating:
2 Duration of symptoms
Risk factors for potentially serious conditions (Red
Flags)
Symptoms suggesting radiculopathy or spinal stenosis
Presence and severity of neurologic deficits
Psychosocial risk factors
(Recommendation 1)

Are any potentially serious


conditions (Red Flags)
strongly suspected?
( Recommendation 2)
(See Table B for Red Flags)

Perform diagnostic studies to


identify cause
(Recommendation 3)
(See Table B for Red Flags)

Specific cause
identified?

N
7

Back pain is mild with no


substantial functional
impairment?

8
Y

Advise about self-care


Review indications for
reassessment
(Recommendation 5)

N
9

10

Advise about self-care (Recommendation 5)


Discuss noninvasive treatment options:
Pharmacologic (Recommendation 6)
Nonpharmacologic (Recommendation 7)

Arrive at shared decision regarding therapy trial


Educate patient

11

Patient accepts risks and


benefit of therapy?

12
Patient on
therapy?

N
15

Continue self-care
Reassess in 1 month if needed

14

Go to Figure 2,
box 16

13

6 Treat specific cause as


Go to Figure 2,
box 19

indicated, consider
consultation

This algorithm should not be used for back pain associated with major trauma, nonspinal back pain, or back pain due to systemic illness.
Extracted and modified from Chou R, Qaseem A, Snow V, et al: Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the
American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

Evaluation & Management of Low Back Pain (October 2011)

State of Oregon Evidence-based Clinical Guidelines Project

Figure 2. Management of low back pain (LBP).

16
LBP not on therapy

17 Initiate time-limited trial of therapy


(see Table C)

18

Follow-up within 4 weeks

19

LBP on therapy

20
Assess response to treatment

21

22

Back pain resolved or


improved with no
significant functional
deficits?

Continue self-care
Reassess in 1 month
if needed
(Recommendation 5)

23

Signs or
symptoms of
radiculopathy or
spinal stenosis?

24 Consider diagnostic imaging (MRI) if


not already done
Consider referral
(Recommendation 4)

N
25

Significant (concordant)
nerve root impingement
or spinal stenosis
present?

N
27
26

30

Reassess symptoms and risk factors


and reevaluate diagnosis
May consider imaging studies
if not already done
(Recommendations 1, 3, 4)

Consider alternative pharmacologic and


nonpharmacologic interventions
(see Table C)
(Recommendations 6, 7)
For significant functional deficit, consider
more intensive multidisciplinary approach or
referral

Use shared decision-making


process to consider possible
options which may include
continued conservative
management, intensive
interdisciplinary approach or
invasive procedures.

28
N

Y
29

Return to box 20

31

Invasive procedure
selected.

Make appropriate
referrals.

Extracted and modified from Chou R, Qaseem A, Snow V, et al: Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the
American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

Evaluation & Management of Low Back Pain (October 2011)

State of Oregon Evidence-based Clinical Guidelines Project

Table B: Potentially Serious Conditions (Red Flags) and Recommendations for Initial
Diagnostic Work-up (Addresses Recommendations 1-4)
Possible cause
Cancer

Key features on history or physical


examination
History of cancer with new onset of LBP
Unexplained weight loss
Failure to improve after 1 month
Age >50 years
Multiple risk factors present

Spinal column infection

Cauda equina syndrome

Vertebral compression fracture

Ankylosing spondylitis

Nerve compression /disorders


(e.g. herniated disc with
radiculopathy)
(Recommendation 4)

Imaging*

Additional studies*

MRI
Lumbosacral
plain
radiography

ESR

Plain
radiography or
MRI

Fever
Intravenous drug use
Recent infection

MRI

ESR and/or CRP

Urinary retention
Motor deficits at multiple levels
Fecal incontinence
Saddle anesthesia

MRI

None

History of osteoporosis
Use of corticosteroids
Older age

Lumbosacral
plain
radiography

None

Morning stiffness
Improvement with exercise
Alternating buttock pain
Awakening due to back pain during the
second part of the night
Younger age

Anteriorposterior pelvis
plain
radiography

ESR and/or CRP, HLAB27

Back pain with leg pain in an L4, L5, or


S1 nerve root distribution
Positive straight-leg-raise test or crossed
straight-leg-raise test

None

None

Radiculopathic symptoms present >1


month
Severe/progressive neurologic deficits,
progressive motor weakness

MRI**

Consider EMG/NCV

Spinal stenosis

Radiating leg pain


Older age
None
(Recommendation 4)
Pain usually relieved with sitting
(Pseudoclaudication a weak predictor)
Spinal stenosis symptoms present >1
MRI**
month
* Level of evidence for diagnostic evaluation is variable
** Only if patient is a potential candidate for surgery or epidural steroid injection

None

Consider EMG/NCV

Red Flag: Red flags are findings from the history and physical examination that may be associated with a higher risk of serious disorders. CRP =
C-reactive protein; EMG = electromyography; ESR = erythrocyte sedimentation rate; MRI = magnetic resonance imaging; NCV = nerve
conduction velocity.
Extracted and modified from Chou R, Qaseem A, Snow V, et al: Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline
from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147:478-491.

Evaluation & Management of Low Back Pain (October 2011)

State of Oregon Evidence-based Clinical Guidelines Project

Table C: Interventions (Addresses Recommendations 5-7)


Intervention Category*

Intervention

Acute
< 4 Weeks

Subacute &
Chronic
> 4 Weeks

Advice to remain active

Self-care
Books, handout

Application of superficial heat

Spinal manipulation

Exercise therapy

Massage

Nonpharmacologic therapy Acupuncture

Yoga

Cognitive-behavioral therapy

Progressive relaxation

Acetaminophen

NSAIDs
()
()
Skeletal
muscle
relaxants

Pharmacologic therapy
Antidepressants (TCA)

(Carefully consider risks/harms)


()
()
Benzodiazepines**
()
()
Tramadol, opioids**
Intensive interdisciplinary
Interdisciplinary therapy

rehabilitation
Interventions supported by grade B evidence (at least fair-quality evidence of moderate benefit, or
small benefit but no significant harms, costs, or burdens). No intervention was supported by grade
A evidence (good-quality evidence of substantial benefit).

Carries greater risk of harms than other agents in table.

NSAIDs = nonsteroidal anti-inflammatory drugs; TCA = tricyclic antidepressants.


*These are general categories only. Individual care plans need to be developed on a case by case basis. For more detailed
information please see: http://www.annals.org/content/147/7/478.full.pdf
**Associated with significant risks related to potential for abuse, addiction and tolerance. This evidence evaluates
effectiveness of these agents with relatively short term use studies. Chronic use of these agents may result in significant
harms.
Extracted and modified from Chou R, Qaseem A, Snow V, et al: Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline
from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147:478-491.

Evaluation & Management of Low Back Pain (October 2011)

State of Oregon Evidence-based Clinical Guidelines Project

Appendix A. Sources Searched for Low Back Pain Guidelines


1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

British Medical Journal Clinical Evidence


Cochrane Library
Agency for Healthcare Research and Quality
ECRI
Hayes, Inc
Veterans Administration Technology Assessment Program (VA TAP)
Blue Cross Blue Shield HTA
Centers for Medicare and Medicaid
CADTH
Washington HTA Program
US Preventive Services Task Force
ICSI
Guidelines.gov
American College of Physicians AND American Pain Society
American Physical Therapy Association
PEDro.org.au (evidence-based physiotherapy database)
GIN Guidelines Database

Evaluation & Management of Low Back Pain (October 2011)

State of Oregon Evidence-based Clinical Guidelines Project

Appendix B. Low Back Pain Guidelines Identified


Methods Summary:
Initially, 17 databases and other sources for guidelines related to Acute Low Back Pain were searched. Candidate
guidelines were required to:
be evidence-based (recommendations based on a full systematic review)
be comprehensive
be published in English
be freely available to the public
Thirteen pertinent guidelines were identified, of which 10 were sufficiently comprehensive and were assessed by
two clinical epidemiologists for methodologic quality using a modified AGREE (Appraisal of Guidelines Research
7
and Evaluation) II instrument.
Candidate guidelines were then assessed considering:
age
source
specific treatment elements addressed
presentation
The GDG selected the two guidelines of highest quality that were most comprehensive. (See guideline text for
comprehensive Methods discussion)
Low Back Pain Guidelines Identified in Search Selected for Quality Assessment
American College of Occupational and Environmental Medicine (ACOEM). (2007). Low back disorders.
Occupational medicine practice guidelines: Evaluation and management of common health problems and
nd
functional recovery in workers. 2 ed. Elk Grove Village, IL: ACOEM.
Overall guideline quality rating: Fair
Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J.T. Jr., Shekelle, P., Owens, D.K., Clinical Efficacy Assessment
Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society
Low Back Pain Guidelines Panel. (2007).Diagnosis and treatment of low back pain: A joint clinical practice
guideline from the American College of Physicians and the American Pain Society. Ann Intern Med, 147(7),
478-91.
Overall guideline quality rating: Good
Institute for Clinical Systems Improvement (ICSI). (2010). Adult low back pain. Fourteenth edition. Bloomington,
MN: ICSI.
Overall guideline quality rating: Poor
Michigan Quality Improvement Consortium. (2008). Management of acute low back pain. Southfield, MI: Michigan
Quality Improvement Consortium.
Overall guideline quality rating: Poor
National Health and Medical Research Council. Australian Acute Musculoskeletal Pain Guidelines Group. (2003).
Evidence-based management of acute musculoskeletal pain. (Website states that status is current). [Chapter
4 of document is on Acute Low Back Pain.]
http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses /cp94.pdf
Overall guideline quality rating: Fair
National Institute for Health and Clinical Excellence (NICE). (2009). Low back pain: Early management of persistent
non-specific low back pain. London, UK: National Institute for Health and Clinical Excellence. Retrieved
September 30, 2010, from http://www.nice.org.uk/nicemedia/live/11887/44343/44343.pdf
Overall guideline quality rating: Good
7

http://www.agreecollaboration.org/

Evaluation & Management of Low Back Pain (October 2011)

10

State of Oregon Evidence-based Clinical Guidelines Project

New Zealand Guidelines Group. (2004). New Zealand acute low back pain guide. Wellington, NZ: New Zealand
Guidelines Group. Retrieved December 13, 2010, from
http://www.nzgg.org.nz/guidelines/0072/acc1038_col.pdf
Overall guideline quality rating: Fair
Philadelphia Panel. (2001). Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation
interventions for low back pain. Physical Therapy, 81(10), 1641-74.
Overall guideline quality rating: Fair
Towards Optimized Practice. (2009). Management of low back pain. Edmonton, AB: Towards Optimized Practice
Program.
Overall guideline quality rating: Fair
University of Michigan Health System. (2010). Acute low back pain. Ann Arbor, MI: University of Michigan Health
System.
Overall guideline quality rating: Poor
Low Back Pain Guidelines Identified in Search Not Selected for Quality Assessment
Burton, A.K., Mller, G., Balagu, F., Gardon, G., Eriksen, H.R., Hnninen, O., et al. (2004). European guidelines for
prevention in low back pain. Retrieved November 22, 2010, from
http://www.backpaineurope.org/web/files/WG3_Guidelines.pdf
Reason for exclusion: Age of underlying evidence review
Davis, P.C., Wippold, F.J. II, Brunberg, J.A., Cornelius, R.S., De La Paz, R.L., Dormont, D., Gray, L, Jordan, J.E.,
Mukherji, S.K., Seidenwurm, D.J., Turski, P.A., Zimmerman, R.D., Sloan, M.A., Expert Panel on Neurologic
Imaging. (2008). ACR Appropriateness Criteria low back pain. Reston, VA: American College of Radiology
(ACR).
Reason for exclusion: Specific treatment elements not addressed
Globe, G.A., Morris, C.E., Whalen, W.M., Farabaugh, R.J., Hawk, C, Council on Chiropractic Guidelines and Practice
Parameter. (2008) Chiropractic management of low back disorders: Report from a consensus process. Journal
of Manipulative Physiological Therapy, 31(9), 651-8.
Reason for exclusion: Specific treatment elements not addressed
McIntosh, G., & Hall, H. (2007). Low back pain (acute). BMJ Clinical Evidence, 10, 1102-1131.
Reason for exclusion: Not a guideline
rd

Resnick, D.K., Choudhri, T.F., Dailey, A.T., Groff, M.W., Khoo, L., Matz, P.G., Mummaneni, P., Watters, W.C. 3 ,
Wang, J., Walters, B.C., Hadley, M.N., American Association of Neurological Surgeons/Congress of
Neurological Surgeons. (2005). Guidelines for the performance of fusion procedures for degenerative disease
of the lumbar spine. Part 2: Assessment of functional outcome. Journal of Neurosurgery: Spine, 2(6), 639-46.
Reason for exclusion: Specific treatment elements not addressed
US Preventive Services Task Force (USPSTF). (2004). Primary care interventions to prevent low back pain in adults.
Rockville, MD: USPSTF.
Reason for exclusion: Recommendations pertain to prevention, not diagnosis or management
Work Loss Data Institute (WLDI). (2008). Low back - lumbar & thoracic (acute & chronic). Corpus Christi, TX: WLDI.
Retrieved November 22, 2010, from http://guidelines.gov/content.aspx?id=12674 [Full version for purchase
only]
Reason for exclusion: Not freely available to the public

Evaluation & Management of Low Back Pain (October 2011)

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State of Oregon Evidence-based Clinical Guidelines Project

Appendix C: Methodology Checklist Adapted from the AGREE II materials

Methodology Checklist: Guidelines


Guideline citation (Include name of organization, title, year of publication, journal title, pages)
Guideline Topic:
Checklist completed by:

Date:

SECTION 1: PRIMARY CRITERIA

To what extent is there


1.1

Assessment/Comments:

RIGOR OF DEVELOPMENT: Evidence

GOOD

FAIR

POOR

GOOD

FAIR

POOR

GOOD

FAIR

POOR

GOOD

FAIR

POOR

Systematic literature search


Study selection criteria clearly described
Quality of individual studies and overall strength of the
evidence assessed
Explicit link between evidence & recommendations
(If any of the above are missing, rate as poor)

1.2

RIGOR OF DEVELOPMENT: Recommendations


Methods for developing recommendations clearly
described
Strengths and limitations of evidence clearly described
Benefits/side effects/risks considered
External review

1.3

EDITORIAL INDEPENDENCE8
Views of funding body have not influenced the content
of the guideline
Competing interests of members have been recorded
and addressed

If any of three primary criteria are rated poor, the entire guideline should be rated poor.

SECTION 2: SECONDARY CRITERIA


2.1

SCOPE AND PURPOSE


Objectives described
Health question(s) specifically described
Population (patients, public, etc.) specified

Editorial Independence is a critical domain. However, it is often very poorly reported in guidelines. The assessor should not rate

the domain, but write unable to assess in the comment section. If the editorial independence is rated as poor, indicating a high
likelihood of bias, the entire guideline should be assessed as poor.

Evaluation & Management of Low Back Pain (October 2011)

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State of Oregon Evidence-based Clinical Guidelines Project

SECTION 2: SECONDARY CRITERIA, Cont.


2.2

STAKEHOLDER INVOLVEMENT

2.3

CLARITY AND PRESENTATION

2.4

APPLICABILITY

GOOD

FAIR

POOR

GOOD

FAIR

POOR

GOOD

FAIR

POOR

GOOD

FAIR

POOR

Relevant professional groups represented


Views and preferences of target population sought
Target users defined

Recommendations specific, unambiguous


Management options clearly presented
Key recommendations identifiable
Application tools available
Updating procedure specified

Provides advice and/or tools on how the


recommendation(s) can be put into practice
Description of facilitators and barriers to its
application
Potential resource implications considered
Monitoring/audit/review criteria presented

SECTION 3: OVERALL ASSESSMENT OF THE GUIDELINE


3.1

How well done is this guideline?

3.2

Other reviewer comments:

Description of Ratings: Methodology Checklist for Guidelines


The checklist for rating guidelines is organized to emphasize the use of evidence in developing guidelines and the
philosophy that evidence is global, guidelines are local. This philosophy recognizes the unique situations (e.g.,
differences in resources, populations) that different organizations may face in developing guidelines for their
constituents. The second area of emphasis is transparency. Guideline developers should be clear about how they
arrived at a recommendation and to what extent there was potential for bias in their recommendations. For these
reasons, rating descriptions are only provided for the primary criteria in section one. There may be variation in
how individuals might apply the good, fair, and poor ratings in section two based on their needs, resources,
organizations, etc.
Section 1. Primary Criteria (rigor of development and editorial independence) ratings:
Good:
Fair:
Poor:

All items listed are present, well described, and well executed (e.g., key research references are included
for each recommendation).
All items are present, but may not be well described or well executed.
One or more items are absent or are poorly conducted

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State of Oregon Evidence-based Clinical Guidelines Project

Appendix D. List of External Reviewers


Invited: Accepted & Reviewed
Susan Bamberger, PT, DIP MDT
President
Oregon Physical Therapy Association
Roger Chou, MD
Scientific Director
Oregon Evidence-based Practice Center
Oregon Health & Science University
Rick Deyo, MD, MPH
Kaiser Permanente Professor of Evidence-Based Family Medicine
Director, KL2 Multidisciplinary Clinical Research Career Development Program
Director, OCTRI Community and Practice-based Research Program
Departments of Family Medicine and Internal Medicine
Oregon Health & Science University
Dorothy Epstein, DPT, OCS
Physical Therapist
Legacy Good Samaritan Pain Management Center
Legacy Good Samaritan Outpatient Rehabilitation
Marc Gosselin, MD
Associate Professor
Director, Thoracic Imaging
Department of Diagnostic Radiology
Oregon Health & Science University
Mitch Haas, DC, MA
Associate Vice President of Research
University of Western States
Luci Kovacevic, MD, MPH
Occupational Medicine Physician
Cascade Medical Associates

Invited: Declined/Did Not Respond/Did Not Review


Thirteen additional reviewers were invited but either declined, did not respond, missed the deadline or did not
return the review. Areas of professional expertise for invited reviewers included:
Behavioral Health
Complementary and Alternative Medicine
Family Medicine
Internal Medicine
Occupational Medicine
Orthopedic Surgery

Evaluation & Management of Low Back Pain (October 2011)

Neurosurgery
Pain Advocacy
Physical Therapy
Physical Medicine and Rehabilitation
Sports Medicine
Workers Compensation

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